Please have your course participants signed SOAR Application before registering them for a course!

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* 1. Peer Support Course Date

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* 2. Course Participant's First and Last Name

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* 3. Course Participant's Email Address

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* 4. Course Participant's Phone Number

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* 5. Course Participant's Burn Injury Date

Date

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* 6. Course Participant's Etiology of Burn

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* 7. Coordinator's First and Last Name

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* 8. Coordinator's Email Address

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* 9. Coordinator's Phone Number

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* 10. Billing Contact's Email Address (If applicable)

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* 11. Please list your hospital, foundation or nonprofit affiliation

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* 12. By checking this box, I acknowledge that payment for this course, pays for a slot on the selected date ONLY. Payment is not transferable or refundable. Please contact the Phoenix Society if further discussion is needed.

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* 13. By checking the box, I acknowledge that payment for the course is due 2 weeks prior, and the participant will complete all the pre-course work on time, in order to attend the course.

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